DIABETES IN PALLIATIVE CARE

Fawad Ahmad (Staff Grade Doctor) and Carey Mills (Blue Team Leader)
Supervised by: Dr Simone Ali (Consultant Palliative Medicine)

Introduction
Diabetes affects about 171 million people worldwide. Current UK prevalence of
diabetes in people over 65 is 10% .In 2005 about 10 million people were diagnosed with
cancer. The incidence of diabetes in patients with cancer is postulated to be higher when
compared to the general population.

Causes of diabetes in patients with advanced disease are multifactorial and include
increased incidence, advanced cancer (i.e. pancreatic), obesity, metabolic changes due to
cancer and use of diabetogenic drugs such as corticosteroids, octreotide and diuretics.

Careful monitoring and control of blood glucose levels via diet and glucose
lowering medicines are essential components of glycemic control. Evidence based
guidelines exist for management of patients with diabetes but glycemic management in
context of advanced cancer varies and lack a suitable evidence base.

Aetiology and Presentation

Diabetes can be primary or secondary. Primary diabetes is where no underlying
cause can be identified. Secondary diabetes occurs when there is underlying pancreatic
disease (pancreatectomy, malignancy and pancreatitis), endocrine disorder (Cushing’s,
acromegaly) or is drug induced.

The diagnosis of diabetes has already been made in the majority of patients who
are referred to palliative care services. However a number of patients will either be
diagnosed or develop diabetes as a result of the treatment.

Commonly presenting symptoms are polyuria, polydipsia, fatigue and weight loss.
A small number of patients present acutely with hyperglycaemic emergencies.

Diagnosis and Monitoring

WHO criteria for diagnosing diabetes are as follows:
1) In asymptomatic patients, fasting blood sugar measurement of 7 mmol/L and
more or random blood sugar measurement of 11 mmol/L and more on two
separate occasions.
2) In symptomatic patients, random blood sugar measurement of more than 11
mmol/L.
3) For borderline patients, definitive diagnosis can be made using a glucose tolerance
test.

Further monitoring in palliative care patients depends upon the stage of

underlying disease. In early stages, diabetic patients should be monitored normally.
Those with advanced disease should be monitored in context of symptom control.

Measurement of capillary blood glucose is most convenient and appropriate test

for continuous monitoring. Glycated haemoglobin indicated control over 2-3 month
period. Urinalysis has limited sensitivity, specificity and cannot detect hypoglycaemia.
Management Issues
Management of diabetes in patients with advanced cancer is complicated by a
number of factors. Blood sugar control depends upon a balance between hypoglycaemic
medication and food intake. Therefore anorexia associated with malignancy affects
glycemic control. Other factors include nausea and vomiting associated with malignancy
or Opioid analgesics, deranged GI motility and obstruction resulting in poor absorption
and medication such as diuretics and steroids used for symptom control.

Management of diabetes may be further complicated because glucose intolerance

is one of the first metabolic consequences of cancer. There is insulin resistance with
increased hepatic glucose production, reduced glucose utilization by skeletal muscle and
reduced skeletal muscle glycogen synthesis.

General Principles of Management

• During the early stage of palliative care where the person may still be active and
have possibly many years left to live, there is no reason why diabetes should not
be managed conventionally.
• As disease progresses and prognosis becomes short term, the importance of
preventing the long-term complications of diabetes become less significant. Both
hyperglycaemia (ketoacidosis, non-osmolar coma) and hypoglycaemia are
uncomfortable, unpleasant and should be avoided. Maintaining a blood glucose
level between 8-15 mmol/L rather than absolute values is important.
• It is important to explain patients and families why a more relaxed approach is
being taken as they may perceive this as giving up on the patient.
• Intensity of monitoring depends upon the expected prognosis.
• Periodic measurement of blood glucose should be done on all patients started on
steroids particularly if patients develop symptoms suggestive of hyperglycaemia.

Management

1) Type 1 or Type 2 insulin controlled

a) Early phase

Range
• Acceptable range: 8-15 mmol/L.
• If BM > 15 mmol/L only treat if symptomatic. Administer up to 5 units of short
acting insulin, e.g. novorapid. Recheck BM after an hour; if BM has remained above
15mmols/L only treat if symptomatic.
Monitoring
• As per usual regime i.e. up to twice a day.
Medication
• Administer Insulin as per usual regime.
Note: Adjust frequency of monitoring and medication depending on condition e.g. decreased
dietary intake, nausea and vomiting.
b) Terminal phase
Range
• Acceptable range 8-15 mmol/L
• If BM >15mmol/L only treat if symptomatic, administer up to 5 units of short
acting insulin, e.g. Novorapid. Recheck BM after an hour; if BM has remained above
15mmol/L only treat if symptomatic.
Monitoring
• Daily pre-insulin BM for 2 days, if asymptomatic and BM> 4 stop all monitoring.
Another option is to continue monitoring BM once a day.
Medication
• Ideally convert to once daily Lantus or twice daily Mixtard. Dose would be up to ½
or 2/3rd of total insulin dose previously taken. If needed contact Diabetes
Specialist Nurses at RSCH for advice.
• Patients who are unconscious or near death, administration of insulin may be
unnecessary because they will not experience the symptoms of hyperglycaemia at
this stage.

2) Type 2, Tablet or Diet controlled

a) Early phase

Range
• Acceptable range 8-15 mmol/L
Monitoring
• Adjust as dictated by condition. Normally glucose levels to be checked up to twice
a week if stable levels seen.
Medication
• Ideally patients should be on short acting sulphonylureas as Gliclazide because it
reduces the incidence of adverse effects of other oral agents.
• Normal dose should be continued for as long as possible. However reduced dose
may be needed because of decreasing oral intake. Concurrent use of diabetogenic
drugs as steroids may require the dose to be increased.
• With deteriorating diabetes control (persistently >15 mmol/L), covert to insulin.
• Adjust as dictated by condition.

b) Terminal phase
• Stop dietary restrictions, monitoring and medication.

References
1) British Diabetic Association-- Guidelines of practice for residents with diabetes in care
homes. 1999

2) Boyd K. Diabetes Mellitus in Hospice patients: some guidelines. Palliative medicine

1993; 7:163-164
3) Poulson J. The management of diabetes in patients with advanced cancer. J pain
symptom management 1997; 13(6):339-346

4) Ford-Dunn S., Quin J. Management of diabetes during the last days of life. Palliative
medicine 2006; 20:197-203

5) Usborne C., Wilding J. Treating diabetes mellitus in palliative care patients. European
journal of palliative care 2003; 10(5):186-188

6) McCann M., White C., Watson M. Practical management of Diabetes Mellitus. European
journal of palliative care 2006; 13(6):226-229

7) Quinn K., Hudson P. Diabetes Management in patients receiving palliative care. J pain
symptom management 2006; 32(3):275-285

8) Smyth T., Smyth D. How to manage diabetes in advanced terminal illness. Nursing
times 2005; 101(17):30-32

9) Tookman A., Wilding J. Guidelines for the management of Diabetes in palliative care.
Merseyside and Cheshire Palliative care network Audit group Jan 2003.